Mental well-being in young people with psychiatric disorders during the early phase of COVID-19 lockdown

Background Mental health and well-being were seriously impacted by the COVID-19 lockdown especially among young people and people with psychiatric disorders. This study aimed to identify factors associated with well-being in young people with psychiatric disorders, during early phase of COVID-19 lockdown in France. Methods A national cross-sectional online study started on the 8th day of COVID-19 lockdown in France (during March 25–30, 2020). We included young people aged from 16 to 29 who responded to the questionnaire, living and being confined in France, with past or current psychiatric treatment. The questionnaire was accessible online and explored demographics and clinical factors, well-being, stress, situation during lockdown. Well-being was measured by the Warwick-Edinburg Mental Well-Being Scale (WEMWBS). Simple and multiple linear regression analyses were carried out. Results 439 individuals were included with 262 (59.7%) previously treated and 177 (40.3%) currently treated. WEMWBS total score were 42.48 (9.05). Feeling of useful was the most affected dimension. Well-being was positively correlated with: currently working on site, physical activity, abilities to cope with difficulties, family and social supports (p<0.05). It was negatively correlated with: elevated stress level, anxious ruminations, dissatisfaction with information, difficulties to sleep or reorganize daily life, feeling supported by medicines (p<0.05). No individual factor was correlated with well-being. The stepwise linear multivariate model had simple R2 coefficient of determination of 0.535. Conclusion In the specific population of young people with psychiatric disorders, factors associated with well-being at early stage of lockdown were mainly psychosocial and related to brutal disorganisation of daily life.


Conclusion
In the specific population of young people with psychiatric disorders, factors associated with well-being at early stage of lockdown were mainly psychosocial and related to brutal disorganisation of daily life.

Materials and data collection
The questionnaire was accessible online via web link, distributed on social networks, online media and mailing lists. Participation was voluntary, without counterpart or sampling. The time to answer was estimated to be between 15 to 30 minutes and the questionnaire could be completed in several times. The platform used was that of INSERM (National Institute on Health and Mental Research). Only one response was possible per Internet Protocol address, to limit multiple responses. It was constructed, with a first and a second version, and available in English in supplementary material. The initial version consisted of 63 questions, quantitative and quantitative, single or multiple choices, divided into 6 domains: (a) Sociodemographic factors, (b) Level of well-being, (c) Level of stress, (d) Medical history with particular emphasis in psychiatric, psychological and addictological histories, (e) Perceptions of the COVID-19 pandemic and lockdown, (f) Lockdown process. Well-being was assessed by the Warwick-Edinburg Mental Well-Being Scale (WEMWBS) [16], translated and validated in French, and with excellent internal consistency [17]. The instrument refers to the last two weeks and consists of 14 items, evaluated according to a 5-point scale, the sum of which leads to an overall score ranging from 14 to 70 with higher scores associated with higher well being (no threshold exists for a state of well being, a former study indicated a mean score of 51.88 in a French student population [17]). A 11-point scale was used for the stress. A cut-off point at 6 were considered for "severe stress". Tables 1 and 2 show relevant questions selected by authorships.

Participants
The inclusion criteria were: (1) age between 16 to 29 years old, (2) living and being confined in France, (3) a past or current psychiatric treatment. Only data from the 8 th to 13 th day of lockdown, i.e. from March 25, 2020 to March 30, 2020 were analysed, to could be compared with the previous analyses [14] and to limit possible time biases. During this period, participants for our study were selected among these above-mentioned population.

Statistical analysis
The software R were used. Incomplete questionnaires were removed. No weighting of the data was performed due to the lack of reference to this specific population. Univariate and bivariate tests by analysis of variance (ANOVA) were performed. Multiple linear regression analyses were performed including candidate variable with a significant bivariate test with a p-value less than 0.1. Given the exploratory nature of the study, a stepwise method was preferred to a hierarchical or non-hierarchical "forced entry" method. The results were considered statistically significant if the p-value was less than 0.05.

Ethics statement
The research board of the Vinatier Hospital (Bron, France) stated that no ethics committee approval was needed and that the project was conducted in accordance with survey ethics. Indeed, as the survey was conducted anonymously with no personal data the EU General Data Protection Regulation (GDPR) of May 25, 2018 did not apply.

Sample characteristics
We analysed data from 439 eligible young people whose questionnaire was fully completed. Main sociodemographic and clinical characteristics were (see Table 1 for more details): 335

Lockdown processing
Main information related to lockdown were (see Table 2 Table 3. 291 (66.3%) of individuals were considered highly stressed (high score > = 6). 194 (44.2%) experienced anxious ruminations for more than one hour per day while 55 (12.5%) were not concerned.

Factors associated with well-being
The simple and multiple linear regression coefficients are presented in Tables 4 and 5. The factors positively correlated with well-being were: work at workplace, physical activity, abilites to cope with difficulties, family and social supports. Those negatively correlated were: elevated stress level, anxious ruminations, dissatisfaction with information provided, difficulties to sleep or reorganize daily life, feeling supported by medications. The physical activity was protector from 30 minutes per day and the effect increased with the duration of practice. Anxious ruminations were strongly and negatively correlated and the coefficients increased according their importance, estimated by daily durations. No individual factor was correlated with wellbeing. The stepwise linear multivariate model had a simple R 2 coefficient of determination of 0.535.

Discussion
This first online study aimed to identify factors associated with well-being, at the early stage of lockdown, in young people concerned by psychiatric disorders. It occurred within the context of psychological health emergency following the COVID-19 pandemic [11,12,18] and aimed at identifying targets for early intervention.

Altered well-being in young people with psychiatric disorders
Studying well-being required caution because of lack of consensual definition of "mental health" and "well-being" [19] and multiplicity of psychometric tools. WEMWBS was chosen for its analysis of both hedonic and eudemonic aspects, over the last two weeks, with good internal consistency and reproducibility [17]. Although, to date, no baseline data on young people with psychiatric disorders were available, our results highlighted significative impairment of wellbeing, with unknown kinetics. Outside pandemic period, French study [17] reported WEMWBS mean score of 44.86 (9.22) among French people suffering from schizophrenia in recovery process. However, such a score, is only partially comparable due to heterogeneity of our sample and the low representation of psychotic disorders. Concerning young workers and students without psychiatric disorders, WEMWBS mean scores were higher of 51.47 (7.19) and 51.88 (6.87) respectively. Scottish study found median score for young people of 53 (IC 95% [52-53]) [16]. First global analysis of our dataset showed, by the second week of lockdown, lower well-being when compared to studies outside lockdown setting among young people, and people with past or actual psychiatric disorder with mean scores of 47.80 (7.23),   [14]. This early impairment of well-being was consistent with the onset of major distress and psychiatric symptoms during this period [4,20,21].

Factors of well-being
Contrary to data in general population, no individual and pre-existing factors of well-being could be identified. All young people with psychiatric disorders, past or currently treated, and whatever the type of disorder, must be considered as at risk. Severe stress and major anxiety were reported by 66.3% and 44.4% of young, in line with literature data showing higher levels in case of psychiatric history [8,20]. To date, major impact of stress in well-being were poorly documented during pandemic while its role on aggravation or onset of psychiatric disorders were established [5][6][7]22]. Being young or suffering from psychiatric disorders increased significantly risk of such psychiatric, but also physical, consequences [5,7,9], due to high vulnerability to stress [10,23].
At the early stage of brutal lockdown, many factors identified in our study refer to the suddenly break and disorganization of daily life. Bidirectional relationships between circadian rhythms and mental health were established in former studies [24]. The importance of routines and regular rhythms justifies psychoeducation of all young people to help them structure their daily life, creating new habits with regular sport and various activities, deciding on regular bedtime. Simple and individual timeframe might be helpful. Limiting late exposure to screens and permanent nibbling could facilitate falling asleep and restoration of dietary rhythms by reappearance of hunger and satiety signals.
Mental health benefits of regular physical activity were observed in general [25] and clinical [26] populations, and during COVID-19 pandemic [27]. Our study found the beneficial threshold of half an hour per day observed in Zhang's study [27], who also noted negative correlation in case of excessive exercise for more than two and half hours per day, without specifying sense of cause-effect link.
Working did not impact well-being, before or during the lockdown but telecommuting was damaging. Interaction analysis could be interesting between working status, psychiatric status and well-being to understand such an indifference which could be the result of reduced interest in work related to recovery process or depressive symptomatology. In general population, (1) Effect size: 0.01-0.06 (low), 0.06-0.14 (medium) and > = 0.14 (high).

PLOS ONE
stop working was associated with lower well-being at the early stage but not telecommuting. [14,27]. Surprisingly, in our study, studying did not increase the risk while it did in general population [5,14]. Our study highlighted that satisfaction with information promoted well-being. Overabundance of information, rumors and misinformation are classic in pandemic context [28] but should be controlled at the risk of serious physical, psychical and social consequences [29,30]. During pandemic periods, information quality strongly conditioned respect of health recommendations [31] and psychological consequences. Information should be clear, easy to access, and concordant between reference sources (government, other decision-making bodies, health professionals), especially for risk levels which easily generates fear [3,30]. At the individual level, the WHO recommended limiting time of exposure and favoring reliable and official sources [32]. Major and increasing use of screens in our study and in the general population made this limitation complex [33]. Information was everywhere, quickly spread and might be intrusive, appearing spontaneous through social networks, newsletters, internet sites. . . Active participation of young people was required to control rumors and media exposure, prevent panic and preserve well-being.
Variations in drug treatment did not interfere with well-being, but young who felt helped could need special attention. Although data on the safety were insufficient at this time [34], continuation of treatment was recommended because of excessive risk of aggravation of psychiatric disorders and withdrawal syndrome [35]. In our study, 97 (39.8%) young people increased their treatment, which could be related to an increase in psychiatric symptomatology [6].

A person-centered approach
Promotion of well-being in pandemic period could be compared to recovery-oriented approach, requiring interdisciplinary collaboration and active participation of young people. Empowerment contributes to supporting eudemonic well-being by reinforcing senses of useful and control [36], self-esteem and self-confidence. After having evaluated risk, psychoeducational interventions could help young people to identify their vulnerabilities, harmful environmental factors, but also their coping skills, recovery strengths and environmental resources in order to boost resilience.
Psychoeducation must be proposed to entire family to promote adaptative family coping and cohesion in order to preserve family support. Communication must be warm, caring, regular and interesting [37]. Stress of lockdown added to burden of disease, leading to high-risk for mental health of caregivers who needed support themselves: impaired well-being, quality of life, depression, isolation and financial difficulties [37][38][39]. During lockdown, 50% of caregivers did not feel supported according to French survey by UNAFAM (The French National Union of Families and Friends of Sick or Psychically Handicapped People) [40].
Individual resilience and social support are highly related [41], which could contribute to protector effect of social support. Sense of cohesion should be strengthened by citizen involvement, neighbourhood solidarity, and promotion interactions, whatever their frequency and with respect for physical distancing measures. Respecting containment is already a responsible and altruistic act that should be valued. Continuing group therapeutic activities could be also interesting to maintaining peer relationships.

Strengths and limitations
Firstly, our study could not analyse kinetics of degradation of well-being and variations over time of different studied variables because of its cross-sectional nature. A cohort study would have been ideal but none ethics committee could be mobilized very quickly in France in March 2020.
Secondly, several recruitment biases must be taken into account. Convenience sampling used for LockUwell survey could explain part of the over-representation of anxiety and depressive disorders and the under-representation of psychotic disorders. However, easy to carry out, it allowed us to quickly obtain a large sample. Need for access to digital technologies, existence of motivational factor due to absence of counterpart, choice of intermediate inclusion criteria also impacted representativeness. As inclusion depended on the presence of current or past psychiatric cares, young people who never engaged with services because of refusal, denial, lack of demand, difficulties in accessing care or non-reporting for fear of stigmatisation or coerced cares were not included. However, psychiatric cares were clinical and relevant criterion, focusing on severity rather than the type of mental disorder.
Thirdly, the setting of our survey, targeting general population with online response limited the level of precision in clinical explorations. Some specific variables to this population could be interesting to improve risk prediction at the start of lockdown: age of onset of disorder, addictions, medications, type of follow-up. . . Current absence of specific risk factors must encourage proactive contact, evaluation and closely support systematically for each young people suffering from psychiatric disorders.

Conclusions
Several factors impacting well-being of young people with psychiatric disorders, at early stage of lockdown, have been identified. Mainly psychosocial and related to brutal disorganisation of daily life, these factors could justify early psychoeducational interventions aiming at boosting resilience, fostering empowerment and promoting social relationships.